病案首页质量控制与信息系统实现方法.doc

病案首页质量控制与信息系统实现方法 　　摘 要 本文分析了影响填写病案首页数据质量的因素，通过改造医院信息系统，建立数据导入视图与数据质量规则监测表，利用系统提供数据监测界面，维护病案首页数据规则监测记录，实现病案首页质量控制。在医生创建病案首页时，系统根据自动数据导入视图加载医院HIS、病理、手麻等系统中的相关数据到病案首页编辑界面中。医生保存病历首页时，系统调用数据导入视图对数据进行一致性校验，调用数据质量规则监测表，对医生填写的记录进行数据规则校验，并将监测结果提示给医生。因此，通过信息系统对医生填写的数据进行监测，极大地提高了医生填写的数据质量，另外利用开放的数据质量规则监测表维护界面，极大地方便了病案人员对数据质量的控制，大大方便了对医院质量管理需求的适应能力。 　　关键词 病案首页 质量控制 影响因素 过程管理 　　中图分类号：R197.323 文献标识码：A DOI：10.16400/j.cnki.kjdkz.2016.10.069 　　Abstract This paper analyzes the impact of fill in data of the first page of medical quality factors， through the transformation of the hospital information system， the establishment of import data view and data quality monitoring rules table， use the system to provide the interface of monitoring data， maintenance data of the first page of medical rules monitoring records， the first page of the medical record quality control. When you create the first page of medical records in the doctor system according to the relevant data in automatic data into view is loaded in his hospital， pathology， numbness in the hand system to the first page of the medical record editing interface. Doctors to keep the medical record homepage， system call data into view of the data for consistency checking， call data quality rules monitoring table， for doctor to complete the record were data validation rules and will monitor the results suggest that the doctor. Therefore， through the information system of doctor to complete the data monitoring， greatly improve the doctor to complete the data quality， in addition to the use of open data quality monitoring rules table maintenance interface， which greatly facilitates the record of data quality control， greatly facilitate the ability to adapt to the needs of hospital quality management. 　　Keywords medical record home； quality control； influencing factors； process management 　　为进一步提高医疗机构科学化、规范化、精细化、信息化管理水平，加强医疗质量管理与控制工作，完善病案管理，国家卫计委组织专家对住院病案首页进行了修订，统一了全国各医院病案首页填写标准，目前首页主要有五大信息内容：病人基本情况、住院诊断、手术及操作情况、其他信息与住院医疗费用分